A federal judge has issued a permanent injunction on behalf of religious health care providers who complained the Biden administration would stipulate the Affordable Care Act requires them to provide medical procedures such as abortions or gender-affirming surgery against their beliefs.

The U.S. Department of Health and Human Services had argued that it doesn't require religious providers to perform such procedures and has never threatened to enforce activity against a religious entity in such a case.

But U.S. District Court Judge Reed O'Connor interpreted HHS regulations as forcing the plaintiffs — a Catholic hospital system in the Midwest and a Christian medical association — to choose between their beliefs and their livelihood, resulting in “irreparable injury."

O'Connor, whose court is in the Northern District of Texas, issued the injunction based on his earlier ruling that found HHS in violation of the Religious Freedom Restoration Act, which requires deference to religion barring a "compelling government interest."

The decision highlights the ongoing tensions between conservative religious health care providers and HHS over an issue that has generated a patchwork of rulings that will fall to appellate courts.

The injunction benefits the Franciscan Alliance, a Catholic hospital network in Indiana and Illinois, and the Christian Medical & Dental Associations and their 19,000 members nationwide.

Another federal judge issued a similar decision in favor of a Catholic health system in North Dakota in January, which the Biden administration is appealing.

The Trump administration strengthened religious exemptions in 2020 and eliminated protections for gender identity, although other federal courts temporarily blocked that change. A successive Supreme Court ruling interpreted the federal ban on sex discrimination as also prohibiting discrimination based on gender identity.

Attorney Luke Goodrich, who represented the plaintiffs on behalf of Becket, a legal organization focused on religious liberty, has praised the decision.

“Everyone is better off when these doctors and hospitals can continue to provide top-notch medical care" without violating their consciences, he said.

Lindsey Kaley, staff attorney with the American Civil Liberties Union's Center for Liberty, said the ruling limits “does not change the fact that transgender people who have been turned away from health care can continue to pursue litigation." The ACLU's Texas branch intervened on behalf of HHS.

“Gender-affirming care is life-saving care, and doctors agree that it is medically necessary for many transgender people," Kaley said.